Nokea
Nurse is caring for many clients during mass casualty event. Which client is highest priority?
- A. Client with crush injuries to chest/abdomen & expected to die
- B. Client with 4-inch laceration to head
- C. Client with partial & full-thickness burns to face, neck, chest
- D. Client with fractured fibula & tibia
Correct Answer: C
Rationale: The correct answer is C because clients with partial & full-thickness burns to face, neck, chest are the highest priority during a mass casualty event. This is due to the potential for airway compromise and risk of respiratory distress. Burns to these areas can cause swelling and compromise the airway, leading to respiratory distress and possible respiratory failure. Immediate intervention is crucial to ensure adequate oxygenation and ventilation. Clients with crush injuries (A) or fractures (D) may have serious injuries but are not at immediate risk of airway compromise. A laceration to the head (B) may require urgent attention but is not as life-threatening as airway compromise.
You may also like to solve these questions
Nurse uses head-to-toe approach to conduct physical assessment of a client who will undergo surgery in 1 week. Which of following attitudes did nurse demonstrate?
- A. confidence
- B. perseverance
- C. integrity
- D. discipline
Correct Answer: D
Rationale: The correct answer is D: discipline. The nurse demonstrated discipline by following a systematic head-to-toe approach in conducting the physical assessment. This method ensures that no area is missed and all aspects of the client's health are thoroughly evaluated. Confidence (A) is important but not specific to the approach used. Perseverance (B) and integrity (C) are important traits but do not directly relate to the method of assessment. By demonstrating discipline, the nurse shows a commitment to thoroughness and professionalism in preparing the client for surgery.
Nursing instructor is reviewing steps of nursing process with group of students. Students should identify which of following data as objective? (Select all that apply.)
- A. Respiratory rate of 22/min with even, unlabored respirations
- B. I can only walk 3 blocks before my legs start to hurt'
- C. Pain level 3/10
- D. Skin pink, warm, dry
- E. Urine output 300 mL/8 hr
- F. Dressing clean, dry, intact
Correct Answer: A, D, E, F
Rationale: Objective data refers to measurable and observable information.
A: Respiratory rate and breathing pattern can be directly observed and counted, making it objective data.
D: Skin color, temperature, and moisture can be seen and felt, making it objective data.
E: Urine output is quantifiable and measurable, making it objective data.
F: The cleanliness, dryness, and integrity of a dressing can be visually assessed, making it objective data.
The other choices involve subjective experiences or interpretations (B), self-reported pain level (C), or may require additional assessments beyond direct observation (G).
Nurse is talking with 45 yo client with no specific family hx of cancer or DM, about planning routine screenings. Which client statement indicates client understands how to proceed?
- A. So I don't need colon cancer procedure for another 2-3 yrs
- B. For now, I should continue to have mammogram each year
- C. Because doctor just did pap smear, I'll come back next year for another
- D. I had my blood glucose test last year so I won't need it again till next year
Correct Answer: B
Rationale: The correct answer is B: "For now, I should continue to have a mammogram each year." This response shows understanding of the need for annual mammograms for breast cancer screening, which is recommended for women aged 45 and older. The other choices are incorrect because: A suggests delaying colon cancer screening, which is typically recommended starting at age 50; C implies annual pap smears, which are usually done every 3-5 years depending on age and risk factors; D indicates a lack of understanding about the frequency of blood glucose testing for diabetes screening.
Nursing instructor explaining various stages of lifespan to students. Nurse should offer which following behavior by young adult as example of appropriate psychosocial development?
- A. "becoming actively involved in providing guidance to next generation"
- B. adjusting to major changes in roles/relationships due to losses
- C. devoting great deal of time to establishing occupation
- D. finding oneself 'sandwiched' between being responsible for 2 generations
Correct Answer: C
Rationale: The correct answer is C because young adults typically focus on establishing their occupation during this stage of development, as per Erikson's theory of psychosocial development. This behavior reflects the stage of intimacy vs. isolation, where individuals strive to form strong relationships and establish a sense of identity through their work. Choice A is incorrect as it pertains more to the generativity vs. stagnation stage, which occurs in middle adulthood. Choice B is incorrect as it aligns with the crisis of integrity vs. despair in late adulthood. Choice D refers to the sandwich generation, which involves caring for both children and aging parents, a challenge typically faced in middle adulthood.
Nurse manager of med-surg unit is assigning care responsibilities for oncoming shift. Client is awaiting transfer back to unit from PACU following thoracic surgery. To which staff member should nurse assign to this client?
- A. Charge nurse
- B. RN
- C. LPN
- D. Assistive personnel (AP)
Correct Answer: B
Rationale: The correct answer is B: RN. The Registered Nurse (RN) is the most appropriate staff member to care for the client awaiting transfer from PACU following thoracic surgery. RNs have the education, training, and scope of practice to assess, monitor, and provide specialized care for post-surgical patients. They can recognize and manage potential complications, administer medications, and coordinate the client's care effectively. Assigning the charge nurse (A) may compromise the overall management of the unit. LPNs (C) have a more limited scope of practice and may not have the necessary skills for post-surgical care. Assistive personnel (D) are not qualified to provide the level of care required for a client following thoracic surgery.